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Sex Therapy With Survivors of Sexual Abuse

I became a sex therapist in the mid-1970s because I was impressed with how well standard sex therapy techniques were able to help people overcome embarrassing problems such as difficulty having an orgasm, painful intercourse, premature ejaculation, and impotence. The use of sex education, self-awareness exercises, and a series of behavioral techniques could cure many of these problems within a matter of only several months. I noticed that as people learned more about the sexual workings of their bodies and gained confidence with their sexual expressions, they would also feel better about themselves in other areas of their lives.

But there were always a number of people in my practice who had difficulty with sex therapy and the specific techniques I gave them as "homework." They would procrastinate and avoid doing the exercises, would do them incorrectly, or, if they could manage some exercises, would report getting nothing out of them. Upon further exploration I discovered that those clients had one major factor in common: a history of childhood sexual abuse.

Besides how they reacted to standard techniques, I noticed other differences between my survivor and nonsurvivor clients. Many survivors seemed ambivalent or neutral about the sexual problems they were experiencing. Gone was the usual sense of frustration that could fuel a client's motivation to change. Survivors often entered counseling because of a partner's frustration with the sexual problems, and they seemed more disturbed by the consequences of sexual problems than by their existence. Margaret, an incest survivor, tearfully confided during her first session, "I'm afraid my husband will leave me if I don't become more interested in sex. Can you help me be the sexual partner he wants me to be?"

Many of the survivors I talked with had been to sex therapists before, with no success. They had histories of persistent problems that seemed immune to standard treatments. What was even more revealing was that survivors kept sharing with me a set of symptoms, in addition to sexual functioning problems, that challenged my skills as a sex therapist. These included --

Avoiding or being afraid of sex. Approaching sex as an obligation. Feeling intense negative emotions when touched, such as fear, guilt, or nausea. Having difficulty with arousal and feeling sensation. Feeling emotionally distant or not present during sex. Having disturbing and intrusive sexual thoughts and fantasies. Engaging in compulsive or inappropriate sexual behaviors. Having difficulty establishing or maintaining an intimate relationship. Considering their sexual histories, touch problems, and responses to counseling, I quickly realized that traditional sex therapy was horribly missing the mark for survivors. Standard treatments such as those described in the early works of William Masters, Virginia Johnson, Lonnie Barbach, Bernie Zilbergeld, and Helen Singer Kaplan often left survivors feeling discouraged, disempowered, and in some cases, retraumatized. Survivors approached sex therapy from an entirely different angle than other clients did. Thus they required an entirely different style and program of sex therapy. Over the course of the last 20 years, the practice of sex therapy has changed considerably. I believe many of these changes were the results of adjustments other sex therapists and I made to be more effective in treating sexual abuse survivors. To illustrate, I will show how sex therapists have challenged and changed six old tenets of traditional sex therapy through treating survivors.

Tenet 1: All Sexual Dysfunctions Are "Bad"

In general, traditional sex therapy viewed all sexual dysfunctions as bad; the goal of treatment being to cure them right away. Techniques were directed toward this goal, and therapeutic success was determined by it. But the sexual dysfunctions of some survivors were, in fact, both functional and important. Their sexual problems helped them avoid feelings and memories associated with past sexual abuse.

When Donna entered therapy for difficulty achieving orgasm, she seemed most concerned with the effect her problem was having on her marriage. She had read many articles and a few books on how to increase orgasmic potential but had never followed through with any suggested exercises. For several months, I worked unsuccessfully with her, trying to help her stick with a sexual enrichment program.

Then we decided to shift the focus of her treatment. I asked Donna about her childhood. She reported some information that hinted at the possibility of childhood sexual abuse. Donna said that during her upbringing her father was an alcoholic whose personality changed when he was drunk. She disliked it whenever he touched her, she pleaded with her mom for a dead-bolt lock on her bedroom door when she was 11 years old, and she had few memories of her childhood in general. After several sessions during which we discussed dynamics in her family of origin, Donna told me she had a very upsetting dream [that included a graphic description of sexual abuse by her father that the client felt was historically true].

In numerous other cases, I encountered a similar process. Steve, a 25-year-old recovering alcoholic, had a chronic problem with premature ejaculation. As we explored his inner psychological experience in therapy, he was able to identify that when he allowed himself to delay ejaculation, he would start to feel an urge to rape his partner. Premature ejaculation was protecting him from this very upsetting feeling. It wasn't until he connected this urge to rape with his intense rage at his mother for sexually abusing him as a child that he was able to resolve the internal conflict and comfortably prolong gratification.

Impressing upon Donna or Steve the idea that their sexual dysfunctions were bad would have done them a disservice. Their dysfunctions were powerful coping techniques. I also encountered another type of situation that challenged the old tenet that sexual dysfunctions are bad. For some survivors who had experienced little difficulty with sexual functioning, the onset of sexual dysfunction signaled a new level of recovery from sexual abuse.

Tony was a 35-year-old single man who had been in and out of abusive relationships for years. His partners were often sexually demanding and generally critical. Tony's father had raped him repeatedly when he was young, and his mother had molested him in his teens. As Tony resolved issues related to his past abuse, his choice of partners improved. One day he told me that he had been unable to function sexually with his new girlfriend. This was extremely unusual for him.